Medicaid expansion under Affordable Care Act associated with increased hospital choice

1. After one year of Medicaid expansion under the Affordable Care Act (ACA), significant changes in emergency department (ED) visits were found in terms of insurance status, visit type, and location in Medicaid expansion states compared to nonexpansion states.

2. These changes suggest that Medicaid expansion offers patients a larger selection of hospital facilities, which can provide a significant context for discussion regarding the effect of the ACA on hospital care access.

Evidence Rating Level: 3 (Average)

Study Rundown: From 2013 to 2014, the ACA has helped approximately 8.8 million uninsured people obtain health insurance. Not much is known about how Medicaid expansion to households making below 138% of the federal poverty level has affected ED use. This study sought to examine how ACA Medicaid expansion has affected ED use in terms of location, insurance status, and visit type. ED visits from the end of 2013 to the end of 2014 for patients from Medicaid expansion states were compared to those from nonexpansion states. The authors found significant changes in ED visits in terms of insurance status, visit type, and location during ACA Medicaid expansion’s first year of implementation. This suggests that Medicaid expansion offers patients a larger selection of hospital facilities. Although research on a wider range of hospitals and over a longer stretch of time is needed, the authors propose that their results offer a significant context for discussion regarding the effect of the ACA on hospital care access.

A strength of the study is that analysis was based on a sample of almost 9 million visits from 126 hospitals. A limitation of the study is that the data came from a group of for-profit, investor-owned hospitals, which limits the conclusions that can be made about ACA effects in facilities such as nonprofit and public hospitals.

Click to read the study in Annals of Internal Medicine

Relevant Reading: Health insurance status change and emergency department use among US adults

In-Depth [interrupted time series]: This quasi-experimental observational study used a 2-group interrupted time-series model for Medicaid expansion and nonexpansion states from 2012 to 2014. To model preexpansion trends, the authors used the 2012 to 2013 monthly time series. Data was used from two large hospital chains with facilities from 17 expansion and 19 nonexpansion states. The patients were uninsured and Medicaid-insured adults from 18 to 64 years of age. A sample of 8 929 881 patient visits were used, with 1 057 818 of these visits coming from patients who lived in expansion states. After one year of ACA implementation, Medicaid expansion state EDs saw a decrease of 47.1% (95%CI, −65.0% to −29.3%) in uninsured visits and an increase of 125.7% (CI, 89.2% to 162.6%) in Medicaid visits compared to a decrease of 5.3% (CI, −24.0 to 13.6) and an increase of 11.4% (CI, −43.6% to 51.3%), respectively, in nonexpansion states. Among nondiscretionary conditions requiring immediate medical treatment, Medicaid expansion state EDs saw a decrease of −41.9% (−53.1% to −30.8%) in uninsured visits and an increase of 212.9 (164.9% to 261.6%) in Medicaid visits compared to an increase of 0.8% (−11.2% to 12.8%) and an increase of 15.7% (−59.9% to 69.4%), respectively, in nonexpansion states. Nondiscretionary conditions saw a decrease of 6.2% (CI, −8.9% to −3.5%) for average travel time among all Medicaid in expansion states compared to a decrease of 0.1% (CI, −7.3% to 7.1%) in nonexpansion states.

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